Nutrition, Physical Activity and

This is one of the 53 country profiles covering developments in nutrition, physical activity and obesity in the WHO European Region. The full set of individual profiles and an overview report including methodology and summary can be downloaded from the WHO Regional Office for website: http://www.euro.who.int/en/nutrition-country-profiles.

© World Health Organization 2013 All rights reserved.

Demographic data Total population 81 373 000

Median age (years) 44.2

Life expectancy at birth (years) female | male 82.7 | 77.7

GDP per capita (US$) 43 918.0

GDP spent on health (%) 11.6 © iStockphoto

Monitoring and surveillance Prevalence of overweight and obesity (%) among Overweight and obesity in three age groups german adults based on WHO 2008 estimates

Adults (18/20 years and over) Intercountry comparable overweight and obesity estimates from 2008 (1) show 66.8 54.5 that 60.5% of the adult population (> 20 years old) in Germany were overweight and 25.1% were obese. The prevalence of overweight was higher among men (66.8%) than women (54.5%). The proportion of men and women that were obese was 25.9% and 24.4%, respectively. 25.9 24.4

Nationally representative data collected in 2008–2011 show that 67.1% of men Source: WHO Global Health Observatory Data Repository (1). and 53.0% of women aged 18–79 years were overweight (based on measured

Prevalence of obesity (%) (BMI ≥30.0 kg/m2) among adults in the WHO European Region based on WHO 2008 estimates

35 30 25 20 15 10 5

0 NO DATA ITA ISL IRL TJK ISR FIN LVA BIH LTU EST SVK PRT CZE ESP BEL AZE KAZ AUT CYP LUX BLR ALB KGZ FRA SVN POL SRB TUR UZB MLT RUS HRV UKR NLD CHE GRC GBR BGR DNK AND DEU GEO TKM ROU HUN NOR SWE SMR MNE MKD ARM MDA MCO 0 10

20 NO DATA 30 40 50 60 70

Prevalence of overweight (%) (BMI ≥25.0 kg/m2) among adults in the WHO European Region based on WHO 2008 estimates

Notes. The country codes refer to the ISO 3166-1 Alpha-3 country codes. Data ranking for obesity is intentionally the same as for the overweight data. BMI: body mass index. Source: WHO Global Health Observatory Data Repository (1).

The Regional Office is grateful to theE uropean Commission (EC) for its financial support for the preparation of this country profile and the development of the nutrition, obesity and physical activity database that provided data for it. height and weight). The proportion of men and women that were obese was 23.3% and 23.9%, respectively (2). It should be taken into account that these Prevalence of overweight (%) IN GermaN ADOLESCENTS (based on self-reported data on height and weight) data do not allow for comparability across countries due to sampling and methodological differences. 23 21 Adulthood obesity prevalence forecasts (2010–2030) predict that in 2020, 20% 14 16 21 12 of men and 18% of women will be obese. By 2030, the model predicts that 24% of men and 21% of women will be obese.1 11-year-olds 13-year-olds 15-year-olds Adolescents (10–19 years) In terms of prevalence of overweight and obesity in adolescents, up to 23% of Source: Currie et al. (3). boys and 14% of girls among 11-year-olds were overweight, according to data from the Health Behaviour in School-aged Children (HBSC) survey (2009/2010).2 Among 13-year-olds, the corresponding figures were 21% for boys and 16% for girls, and among 15-year-olds, 21% and 12%, respectively (3).

Children (0–9 years) No prevalence figures are available for overweight and obesity in schoolchildren based on measured intercountry comparable data. Germany is not yet participating in the WHO European Surveillance Initiative (COSI).

However, nationally representative data (based on measurements of height and weight) from 2003–2006 show that 9.1% of children aged 3–6 years (8.9% boys, 9.3% girls) and 15.4% of children aged 7–10 years (15.9% boys, 14.7% girls) were overweight (4). A total of 2.9% of the children aged 3–6 years (2.5% boys, 3.3% girls) and 6.4% of those aged 7–10 years (7.0% boys, 5.7% girls) were obese. It should be taken into account that these figures (which are based on the Kromeyer-Hauschild et al. growth reference (5)) do not allow for comparability across countries.

Exclusive breastfeeding until 6 months of age Nationally representative data from 2003–2006 show that the prevalence of exclusive breastfeeding at 6 months of age was 22.4% in Germany.3

Prevalence of exclusive breastfeeding (%) under or at 6 months of age from individual country-based surveys, various years

60 Under 6 months of age At 6 months of age 50 At 3, 4 or 5 months of age

40

30

20

10 NO NATIONAL DATA 0 ITA ISL IRL TJK FIN ISR LVA BIH LTU EST SVK PRT CZE ESP KAZ AZE BEL AUT CYP ALB KGZ LUX BLR FRA SVN SRB UZB TUR POL MLT HRV RUS CHE NLD UKR GRC DNK GBR BGR DEU AND GEO TKM ROU HUN NOR SMR SWE MNE MKD ARM MDA MCO

Notes. The country codes refer to the ISO 3166-1 Alpha-3 country codes. Data were derived from country-specific publications on surveys carried out in this field, not as part of a European- wide survey. Due to different data collection methods of the country-specific surveys, any comparisons between countries must be made with caution. Source: WHO Regional Office for Europe grey literature from 2012 on breastfeeding.

Saturated fat intake According to the 2007 estimates of the Food and Agriculture Organization of the United Nations (FAO), the adult population in Germany consumed 11.7% of their total calories from saturated fatty acids (6). According to national data from 2012, male adults consumed 15.7% and female adults consumed 15.4% of their total calorie intake from saturated fatty acids (7). It should be taken into account that these latter, national data do not allow for comparability across countries due to sampling and methodological differences.

1 Report on modelling adulthood obesity across the WHO European Region, prepared by consultants (led by T. Marsh and colleagues) for the WHO Regional Office for Europe in 2013. 2 Based on 2007 WHO growth reference. 3 WHO Regional Office for Europe grey literature from 2012 on breastfeeding. Proportion of energy from saturated fatty acids (%) among adults in the WHO European Region, 2007

16 14 12 FAO RECOMMENDATION - max. 10% energy 10 8 6 4 2 0 NO DATA ITA ISL IRL TJK ISR FIN LVA BIH LTU EST SVK PRT AZE CZE KAZ BEL ESP AUT CYP KGZ ALB BLR FRA LUX SVN TUR UZB SRB POL MLT HRV RUS UKR CHE NLD GRC DNK BGR GBR TKM AND GEO DEU ROU NOR HUN SMR SWE MNE MKD ARM MDA MCO

Notes. The country codes refer to the ISO 3166-1 Alpha-3 country codes. Ranking of data was carried out so that country data at the right-hand side of the graph – with values below the FAO recommendation – fall within the positive frame of the indicator. Source: FAOSTAT (6).

Fruit and vegetable supply Germany had a fruit and vegetable supply of 482 grams per capita per day, according to 2009 estimates (6).

Fruit and vegetable supply (GRAMS) per person per day in the WHO European Region, 2009

1200

1000

800 WHO/FAO RECOMMENDATION - >600 grams 600

400

200

0 NO DATA ITA ISL IRL TJK ISR FIN BIH LVA LTU EST SVK PRT ESP KAZ BEL AZE CZE AUT LUX ALB BLR CYP KGZ FRA SVN SRB UZB TUR POL MLT RUS HRV NLD CHE UKR GRC DNK GBR BGR DEU TKM GEO AND ROU HUN NOR SWE SMR MNE MKD ARM MDA MCO

Notes. The country codes refer to the ISO 3166-1 Alpha-3 country codes. Ranking of data was carried out so that country data at the right-hand side of the graph – with values above the WHO/FAO recommendation – fall within the positive frame of the indicator. Source: FAOSTAT (6).

Salt intake Data from 2011 show that salt intake in Germany was 9.0 grams per day for men and 6.5 grams per day for women (8).

Salt intake (GRAMS) per person per day for adults in the WHO European Region from individual country-based surveys, various years

16 14 12 10 8 WHO/FAO RECOMMENDATION - <5 grams 6 4 2 0 NO NATIONAL DATA ITA ISL IRL TJK FIN ISR LVA BIH LTU EST SVK PRT ESP CZE BEL AZE KAZ AUT LUX FRA CYP ALB BLR KGZ SVN TUR UZB POL SRB MLT HRV RUS CHE NLD UKR GRC GBR BGR DNK DEU AND GEO TKM ROU HUN NOR SWE SMR MKD ARM MNE MDA MCO

Notes. The country codes refer to the ISO 3166-1 Alpha-3 country codes. Data were derived from country-specific publications on surveys carried out in this field, not as part of a European- wide survey. Due to different data collection methods of the country-specific surveys, any comparisons between countries must be made with caution. Ranking of data was carried out so that country data at the right-hand side of the graph – with values below the WHO/FAO recommendation – fall within the positive frame of the indicator. Source: WHO Regional Office for Europe (8).

Iodine status According to the most recent estimates on iodine status, published in 2012, the proportion of the population with an iodine level lower than 100 µg/L was 38.8% (9, 10). Physical inactivity In Germany, 46.6% of the population aged 15 years and over were insufficiently active (men 43.6% and women 49.4%), according to estimates generated for 2008 by WHO (1). A national survey carried out in 2008–2011 revealed that 74.6% of men and 84.5% of women aged 18–79 years were physically active for less than 2.5 hours per week (11). It should be taken into account that these latter data do not allow for comparability across countries due to sampling and methodological differences. Policies and actions The table below displays (a) monitoring and evaluation methods of salt intake in Germany; (b) the stakeholder approach toward salt reduction; and (c) the population approach in terms of labelling and consumer awareness initiatives (8).

Salt reduction initiatives

Monitoring & evaluation Stakeholder approach Population approach Labelling Consumer awareness initiatives Industry self-reporting Brochure TV Website Education Conference Reporting Specific Industry Food Print Radio Software Salt content in food 88 (bread) food involvement reformulation Schools category 888 Salt intake Health Consumer awareness care facilities Behavioural change

Urinary salt excretion (24 hrs) 888 88 88

Notes. 88 partially implemented; 888 fully implemented. Source: WHO Regional Office for Europe (8).

Trans fatty acids (TFA) policies Price policies (food taxation and subsidies)

Legislation Type of legislation Measure Taxes School fruit schemes Voluntary Voluntary industry action 4

Source: WHO Regional Office for Europe grey literature from 2012 on TFA and health, TFA policy and food Sources: WHO Regional Office for Europe grey literature from 2012 industry approaches. on diet and the use of fiscal policy in the control and prevention of noncommunicable diseases; EC School Fruit Scheme website (12).

Marketing of food and non-alcoholic beverages to children (13) The Federal Ministry of Health and the Federal Ministry of Food, Agriculture and Consumer Protection have made the promotion of healthy lifestyles the main health and nutrition policy objective, placing strong emphasis on reducing overweight and obesity. The Federal Government’s National Action Plan (14) “IN FORM – German national initiative to promote healthy diets and physical activity” involves – inter alia – meetings with industry aimed at preventing any advertising targeting children aged under 12 years of age and formulating a voluntary code of conduct for advertising activities targeting older children and adolescents.

According to federal law, marketing must comply with the legal framework established to control unfair competition (15). The law prohibits any type of advertising that directly invites children to buy a marketed product themselves or to take up a marketed service themselves, or cause their parents or other adults to do so. Advertising on the radio and TV (as well as teleshopping) are subject to provisions on the protection of minors set out in section 6 of the Interstate Treaty on the Protection of Human Dignity and the Protection of Minors in Broadcasting and in Telemedia (16).

In 2009 the German Advertising Federation (17) developed a special Code of Conduct on Commercial Communication for Foods and Beverages for the protection of children with regard to advertising on radio and TV (18). The general rules of the code emphasize that advertising should not: (a) abuse consumers’ confidence; (b) undermine a healthy and active lifestyle; (c) undermine a balanced and healthy diet; or (d) encourage excessive consumption. The code stipulates that there should be: (a) no direct demand for children to purchase; (b) no direct demand for children to convince their parents to purchase; (c) no exploitation of children’s confidence and; (d) no inducements to purchase.

Physical activity (PA), national policy documents and action plans

Sport Target groups Health Education Transportation

Existence of national Existence of specific scheme or Counselling on Mandatory Inclusion of National or subnational Existence of an incentive ”sport for all” policy programme for community PA as part of physical PA in general schemes promoting active scheme for companies or and/or national ”sport interventions to promote PA in the primary health care education in teaching travel to school employees to promote active for all” implementation elderly activities primary and training travel to work programme secondary schools

4 4 4b 4a a Clearly stated in a policy document, partially implemented or enforced. b Clearly stated in a policy document, entirely implemented and enforced. Source: country reporting template on Germany from 2009 developed in the context of a WHO/EC project on monitoring progress on improving nutrition and PA and preventing obesity in the European Union (EU). Leadership, partnerships and professional networks on health-enhancing physical activity (HEPA)

Existence of national coordination Leading institution Participating bodies mechanism on HEPA promotion Government departments on health, agriculture, food, consumer affairs, Federal Ministry of Health and Federal sport, transport, urban planning, education and research, social welfare, 4 2007 Ministry of Food, Agriculture and labour, culture; nongovernmental organizations; academia; civil society; Consumer Protection communities; private sector

Source: country reporting template on Germany from 2009 developed in the context of a WHO/EC project on monitoring progress on improving nutrition and PA and preventing obesity in the EU.

PA recommendations, goals and surveillance

Existence of national Target groups adressed by PA included in the recommendation on HEPA national HEPA policy national health monitoring system

4 General population 4

Source: country reporting template on Germany from 2009 developed in the context of a WHO/EC project on monitoring progress on improving nutrition and PA and preventing obesity in the EU. References 1. WHO Global Health Observatory Data Repository [online database]. Geneva, World Health Organization, 2013 (http://apps.who.int/gho/data/view.main, accessed 21 May 2013). 2. Mensink GBM et al. Overweight and obesity in Germany: results of the German health interview and examination survey for adults (DEGS1). Bundesgesundheitsblatt, Gesundheitsforschung, Gesundheitsschutz, 2013, 56:786–794. 3. Currie C et al., eds. Social determinants of health and well-being among young people: Health Behaviour in School-aged Children (HBSC) study: international report from the 2009/2010 survey. Copenhagen, WHO Regional Office for Europe, 2012 (Health Policy for Children and Adolescents, No. 6) (http://www.euro.who.int/__data/assets/pdf_file/0003/163857/Social- determinants-of-health-and-well-being-among-young-people.pdf, accessed 21 May 2013). 4. Kurth BM, Schaffrath Rosario A. Die Verbreitung von Übergewicht und Adipositas bei Kindern und Jugendlichen in Deutschland. Ergebnisse des bundesweiten Kinder- und Jugendgesundheitssurveys (KiGGS). Bundesgesundheitsblatt, Gesundheitsforschung, Gesundheitsschutz, 2007, 50:736–743. 5. Kromeyer-Hauschild K et al. Perzentile für den Body-Mass-Index für das Kindes- und Jugendalter unter Heranziehung verschiedener deutscher Stichproben. Monatsschrift für Kinderheilkunde, 2001, 149:807–818. 6 FAOSTAT [online database]. Rome, Statistics Division of the Food and Agriculture Organization of the United Nations, 2013 (http://faostat.fao.org/, accessed 21 May 2013). 7. 12 Ernährungsbericht 2012. Bonn, Deutsche Gesellschaft für Ernährung e.V., 2012. 8. Mapping salt reduction initiatives in the WHO European Region. Copenhagen, WHO Regional Office for Europe, 2013(http://www.euro.who.int/__data/assets/pdf_file/0009/186462/ Mapping-salt-reduction-initiatives-in-the-WHO-European-Region-final.pdf, accessed 29 May 2013). 9. Andersson M, Karumbunathan V, Zimmermann MB. Global iodine status in 2011 and trends over the past decade. Journal of Nutrition, 2012, 142(4):744–750. 10. Zimmerman MB, Andersson M. Update on iodine status worldwide. Current Opinion in Endocrinology, Diabetes and Obesity, 2012, 19(5):382–387. 11. Krug S et al. Physical activity: results of the German health interview and examination survey for adults (DEGS1). Bundesgesundheitsblatt, Gesundheitsforschung, Gesundheitsschutz, 2013, 56:765–771. 12. School Fruit Scheme [website]. Brussels, European Commission Directorate-General for Agriculture and Rural Development, 2012 (http://ec.europa.eu/agriculture/sfs/eu-countries/ index_en.htm, accessed 21 May 2013). 13. Marketing of foods high in fat, salt and sugar to children: update 2012–2013. Copenhagen, WHO Regional Office for Europe, 2013 (http://www.euro.who.int/__data/assets/pdf_ file/0019/191125/e96859.pdf, accessed 10 October 2013). 14. IN FORM – Deutschlands Initiative für gesunde Ernährung und mehr Bewegung. , Ministry of Food, Agriculture and Consumer Protection and Ministry of Health, 2008 (http:// www.bmelv.de/SharedDocs/Downloads/Broschueren/AktionsplanINFORM.pdf?__blob=publicationFile, accessed 24 July 2013). 15. The Act Against Unfair Competition. Federal Law Gazette (BGBI), 2010, Part 1:254 (http://www.gesetze-im-internet.de/englisch_uwg/englisch_uwg.html, accessed 24 July 2013). 16. Interstate Treaty on the Protection of Human Dignity and the Protection of Minors in Broadcasting and in Telemedia. Munich, Commission of the State Media Authority for Youth Media Protection, 2010 (http://www.kjm-online.de/files/pdf1/_JMStV_Stand_13_RStV_mit_Titel_english.pdf, accessed 24 July 2013). 17. ZAW.Online [website]. Berlin, Central Association of the German Advertising Industry, 2013 (http://www.zaw.de/, accessed 25 July 2013). 18. German Standards Advertising Council Code of Conduct on Commercial Communication for Foods and Beverages. Berlin, German Advertising Federation, 2009 (http://www. werberat.de/sites/default/files/uploads/media/dw_commercial_communication_on_foods_2009.pdf, accessed 22 July 2013).